<INTERCHANGE xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema" xmlns="www.edifabric.com/x12">
  <S_ISA>
    <D_744_1>00</D_744_1>
    <D_745_2>          </D_745_2>
    <D_746_3>00</D_746_3>
    <D_747_4>          </D_747_4>
    <D_704_5>ZZ</D_704_5>
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    <D_704_7>33</D_704_7>
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    <D_373_9>110406</D_373_9>
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    <D_726_11>^</D_726_11>
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    <D_709_13>000000312</D_709_13>
    <D_749_14>1</D_749_14>
    <D_748_15>P</D_748_15>
    <D_701_16>:</D_701_16>
  </S_ISA>
  <GROUPS>
    <GROUP>
      <S_GS>
        <D_479_1>HC</D_479_1>
        <D_142_2>010101010</D_142_2>
        <D_124_3>7306849549</D_124_3>
        <D_29_4>20110406</D_29_4>
        <D_30_5>0857</D_30_5>
        <D_28_6>312</D_28_6>
        <D_455_7>X</D_455_7>
        <D_480_8>004010X098A1</D_480_8>
      </S_GS>
      <MESSAGES>
        <MESSAGE>
          <Item>
            <M_837>
              <S_ST>
                <D_ST01>837</D_ST01>
                <D_ST02>0001</D_ST02>
                <D_ST03>004010X098A1</D_ST03>
              </S_ST>
              <S_BHT_BeginningOfHierarchicalTransaction_TS837Q1>
                <D_BHT01_HierarchicalStructureCode>0019</D_BHT01_HierarchicalStructureCode>
                <D_BHT02_TransactionSetPurposeCode>00</D_BHT02_TransactionSetPurposeCode>
                <D_BHT03_OriginatorApplicationTransactionIdentifier>1</D_BHT03_OriginatorApplicationTransactionIdentifier>
                <D_BHT04_TransactionSetCreationDate>20110406</D_BHT04_TransactionSetCreationDate>
                <D_BHT05_TransactionSetCreationTime>085755</D_BHT05_TransactionSetCreationTime>
                <D_BHT06_ClaimOrEncounterIdentifier>CH</D_BHT06_ClaimOrEncounterIdentifier>
              </S_BHT_BeginningOfHierarchicalTransaction_TS837Q1>
              <G_TS837Q1_1000A>
                <S_NM1_SubmitterName_TS837Q1_1000A>
                  <D_NM101_EntityIdentifierCode>41</D_NM101_EntityIdentifierCode>
                  <D_NM102_EntityTypeQualifier>2</D_NM102_EntityTypeQualifier>
                  <D_NM103_SubmitterLastOrOrganizationName>LINE MEDICAL ASSOCIATES</D_NM103_SubmitterLastOrOrganizationName>
                  <D_NM108_IdentificationCodeQualifier>46</D_NM108_IdentificationCodeQualifier>
                  <D_NM109_SubmitterIdentifier>010101010</D_NM109_SubmitterIdentifier>
                </S_NM1_SubmitterName_TS837Q1_1000A>
                <S_PER_SubmitterEDIContactInformation_TS837Q1_1000A>
                  <D_PER01_ContactFunctionCode>IC</D_PER01_ContactFunctionCode>
                  <D_PER02_SubmitterContactName>KEVIN</D_PER02_SubmitterContactName>
                  <D_PER03_CommunicationNumberQualifier>TE</D_PER03_CommunicationNumberQualifier>
                  <D_PER04_CommunicationNumber>4124541000</D_PER04_CommunicationNumber>
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              <G_TS837Q1_1000B>
                <S_NM1_ReceiverName_TS837Q1_1000B>
                  <D_NM101_EntityIdentifierCode>40</D_NM101_EntityIdentifierCode>
                  <D_NM102_EntityTypeQualifier>2</D_NM102_EntityTypeQualifier>
                  <D_NM103_ReceiverName>UPMC</D_NM103_ReceiverName>
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                  <D_NM109_ReceiverPrimaryIdentifier>7306849549</D_NM109_ReceiverPrimaryIdentifier>
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              <G_TS837Q1_2000A>
                <S_HL_BillingPaytoProviderHierarchicalLevel_TS837Q1_2000A>
                  <D_HL01_HierarchicalIDNumber>1</D_HL01_HierarchicalIDNumber>
                  <D_HL03_HierarchicalLevelCode>20</D_HL03_HierarchicalLevelCode>
                  <D_HL04_HierarchicalChildCode>1</D_HL04_HierarchicalChildCode>
                </S_HL_BillingPaytoProviderHierarchicalLevel_TS837Q1_2000A>
                <S_PRV_BillingPaytoProviderSpecialtyInformation_TS837Q1_2000A>
                  <D_PRV01_ProviderCode>BI</D_PRV01_ProviderCode>
                  <D_PRV02_ReferenceIdentificationQualifier>ZZ</D_PRV02_ReferenceIdentificationQualifier>
                  <D_PRV03_ProviderTaxonomyCode>208000000X</D_PRV03_ProviderTaxonomyCode>
                </S_PRV_BillingPaytoProviderSpecialtyInformation_TS837Q1_2000A>
                <A_TS837Q1_2010A>
                  <G_TS837Q1_2010AA>
                    <S_NM1_BillingProviderName_TS837Q1_2010AA>
                      <D_NM101_EntityIdentifierCode>85</D_NM101_EntityIdentifierCode>
                      <D_NM102_EntityTypeQualifier>1</D_NM102_EntityTypeQualifier>
                      <D_NM103_BillingProviderLastOrOrganizationalName>LINE</D_NM103_BillingProviderLastOrOrganizationalName>
                      <D_NM104_BillingProviderFirstName>WILLIAM</D_NM104_BillingProviderFirstName>
                      <D_NM105_BillingProviderMiddleName>J</D_NM105_BillingProviderMiddleName>
                      <D_NM108_IdentificationCodeQualifier>XX</D_NM108_IdentificationCodeQualifier>
                      <D_NM109_BillingProviderIdentifier>01010101</D_NM109_BillingProviderIdentifier>
                    </S_NM1_BillingProviderName_TS837Q1_2010AA>
                    <S_N3_BillingProviderAddress_TS837Q1_2010AA>
                      <D_N301_BillingProviderAddressLine>123 PEPPER ST</D_N301_BillingProviderAddressLine>
                    </S_N3_BillingProviderAddress_TS837Q1_2010AA>
                    <S_N4_BillingProviderCityStateZIPCode_TS837Q1_2010AA>
                      <D_N401_BillingProviderCityName>PITTSBURGH</D_N401_BillingProviderCityName>
                      <D_N402_BillingProviderStateOrProvinceCode>PA</D_N402_BillingProviderStateOrProvinceCode>
                      <D_N403_BillingProviderPostalZoneOrZIPCode>15123</D_N403_BillingProviderPostalZoneOrZIPCode>
                    </S_N4_BillingProviderCityStateZIPCode_TS837Q1_2010AA>
                    <I_REF_TS837Q1_2010AA>
                      <S_REF_BillingProviderSecondaryIdentification_TS837Q1_2010AA>
                        <D_REF01_ReferenceIdentificationQualifier>EI</D_REF01_ReferenceIdentificationQualifier>
                        <D_REF02_BillingProviderAdditionalIdentifier>260110222</D_REF02_BillingProviderAdditionalIdentifier>
                      </S_REF_BillingProviderSecondaryIdentification_TS837Q1_2010AA>
                    </I_REF_TS837Q1_2010AA>
                    <S_PER_BillingProviderContactInformation_TS837Q1_2010AA>
                      <D_PER01_ContactFunctionCode>IC</D_PER01_ContactFunctionCode>
                      <D_PER02_BillingProviderContactName> KEVIN</D_PER02_BillingProviderContactName>
                      <D_PER03_CommunicationNumberQualifier>TE</D_PER03_CommunicationNumberQualifier>
                      <D_PER04_CommunicationNumber>4124541000</D_PER04_CommunicationNumber>
                    </S_PER_BillingProviderContactInformation_TS837Q1_2010AA>
                  </G_TS837Q1_2010AA>
                </A_TS837Q1_2010A>
                <G_TS837Q1_2000B>
                  <S_HL_SubscriberHierarchicalLevel_TS837Q1_2000B>
                    <D_HL01_HierarchicalIDNumber>2</D_HL01_HierarchicalIDNumber>
                    <D_HL02_HierarchicalParentIDNumber>1</D_HL02_HierarchicalParentIDNumber>
                    <D_HL03_HierarchicalLevelCode>22</D_HL03_HierarchicalLevelCode>
                    <D_HL04_HierarchicalChildCode>0</D_HL04_HierarchicalChildCode>
                  </S_HL_SubscriberHierarchicalLevel_TS837Q1_2000B>
                  <S_SBR_SubscriberInformation_TS837Q1_2000B>
                    <D_SBR01_PayerResponsibilitySequenceNumberCode>P</D_SBR01_PayerResponsibilitySequenceNumberCode>
                    <D_SBR02_IndividualRelationshipCode>18</D_SBR02_IndividualRelationshipCode>
                    <D_SBR04_InsuredGroupName>BEST UPMC FOR YOU</D_SBR04_InsuredGroupName>
                    <D_SBR09_ClaimFilingIndicatorCode>CI</D_SBR09_ClaimFilingIndicatorCode>
                  </S_SBR_SubscriberInformation_TS837Q1_2000B>
                  <A_TS837Q1_2010B>
                    <G_TS837Q1_2010BA>
                      <S_NM1_SubscriberName_TS837Q1_2010BA>
                        <D_NM101_EntityIdentifierCode>IL</D_NM101_EntityIdentifierCode>
                        <D_NM102_EntityTypeQualifier>1</D_NM102_EntityTypeQualifier>
                        <D_NM103_SubscriberLastName>KENT</D_NM103_SubscriberLastName>
                        <D_NM104_SubscriberFirstName>CLARK</D_NM104_SubscriberFirstName>
                        <D_NM105_SubscriberMiddleName>S</D_NM105_SubscriberMiddleName>
                        <D_NM108_IdentificationCodeQualifier>MI</D_NM108_IdentificationCodeQualifier>
                        <D_NM109_SubscriberPrimaryIdentifier>00000000101</D_NM109_SubscriberPrimaryIdentifier>
                      </S_NM1_SubscriberName_TS837Q1_2010BA>
                      <S_N3_SubscriberAddress_TS837Q1_2010BA>
                        <D_N301_SubscriberAddressLine>123 FAKE STREET</D_N301_SubscriberAddressLine>
                      </S_N3_SubscriberAddress_TS837Q1_2010BA>
                      <S_N4_SubscriberCityStateZIPCode_TS837Q1_2010BA>
                        <D_N401_SubscriberCityName>PITTSBURGH</D_N401_SubscriberCityName>
                        <D_N402_SubscriberStateCode>PA</D_N402_SubscriberStateCode>
                        <D_N403_SubscriberPostalZoneOrZIPCode>15123</D_N403_SubscriberPostalZoneOrZIPCode>
                      </S_N4_SubscriberCityStateZIPCode_TS837Q1_2010BA>
                      <S_DMG_SubscriberDemographicInformation_TS837Q1_2010BA>
                        <D_DMG01_DateTimePeriodFormatQualifier>D8</D_DMG01_DateTimePeriodFormatQualifier>
                        <D_DMG02_SubscriberBirthDate>20060503</D_DMG02_SubscriberBirthDate>
                        <D_DMG03_SubscriberGenderCode>M</D_DMG03_SubscriberGenderCode>
                      </S_DMG_SubscriberDemographicInformation_TS837Q1_2010BA>
                    </G_TS837Q1_2010BA>
                    <G_TS837Q1_2010BB>
                      <S_NM1_PayerName_TS837Q1_2010BB>
                        <D_NM101_EntityIdentifierCode>PR</D_NM101_EntityIdentifierCode>
                        <D_NM102_EntityTypeQualifier>2</D_NM102_EntityTypeQualifier>
                        <D_NM103_PayerName>UPMC HEALTH PLAN</D_NM103_PayerName>
                        <D_NM108_IdentificationCodeQualifier>PI</D_NM108_IdentificationCodeQualifier>
                        <D_NM109_PayerIdentifier>7306849549</D_NM109_PayerIdentifier>
                      </S_NM1_PayerName_TS837Q1_2010BB>
                      <S_N3_PayerAddress_TS837Q1_2010BB>
                        <D_N301_PayerAddressLine>1 CHATHAM CENTER 112 WASHINGTON</D_N301_PayerAddressLine>
                        <D_N302_PayerAddressLine>PO BOX 2995</D_N302_PayerAddressLine>
                      </S_N3_PayerAddress_TS837Q1_2010BB>
                      <S_N4_PayerCityStateZIPCode_TS837Q1_2010BB>
                        <D_N401_PayerCityName>PITTSBURGH</D_N401_PayerCityName>
                        <D_N402_PayerStateCode>PA</D_N402_PayerStateCode>
                        <D_N403_PayerPostalZoneOrZIPCode>15230</D_N403_PayerPostalZoneOrZIPCode>
                      </S_N4_PayerCityStateZIPCode_TS837Q1_2010BB>
                    </G_TS837Q1_2010BB>
                  </A_TS837Q1_2010B>
                  <G_TS837Q1_2300>
                    <S_CLM_ClaimInformation_TS837Q1_2300>
                      <D_CLM01_PatientAccountNumber>2152414902600312</D_CLM01_PatientAccountNumber>
                      <D_CLM02_TotalClaimChargeAmount>47.28</D_CLM02_TotalClaimChargeAmount>
                      <C_CLM05_C023U837_TS837Q1_2300>
                        <D_CLM05_C02301U838_FacilityTypeCode>11</D_CLM05_C02301U838_FacilityTypeCode>
                        <D_CLM05_C02303U840_ClaimFrequencyCode>1</D_CLM05_C02303U840_ClaimFrequencyCode>
                      </C_CLM05_C023U837_TS837Q1_2300>
                      <D_CLM06_ProviderOrSupplierSignatureIndicator>Y</D_CLM06_ProviderOrSupplierSignatureIndicator>
                      <D_CLM07_MedicareAssignmentCode>A</D_CLM07_MedicareAssignmentCode>
                      <D_CLM08_BenefitsAssignmentCertificationIndicator>Y</D_CLM08_BenefitsAssignmentCertificationIndicator>
                      <D_CLM09_ReleaseOfInformationCode>Y</D_CLM09_ReleaseOfInformationCode>
                      <D_CLM10_PatientSignatureSourceCode>B</D_CLM10_PatientSignatureSourceCode>
                    </S_CLM_ClaimInformation_TS837Q1_2300>
                    <I_DTP_TS837Q1_2300>
                      <S_DTP_DateDateLastSeen_TS837Q1_2300>
                        <D_DTP01_DateTimeQualifier>304</D_DTP01_DateTimeQualifier>
                        <D_DTP02_DateTimePeriodFormatQualifier>D8</D_DTP02_DateTimePeriodFormatQualifier>
                        <D_DTP03_LastSeenDate>20110405</D_DTP03_LastSeenDate>
                      </S_DTP_DateDateLastSeen_TS837Q1_2300>
                      <S_DTP_DateOnsetOfCurrentIllnessSymptom_TS837Q1_2300>
                        <D_DTP01_DateTimeQualifier>431</D_DTP01_DateTimeQualifier>
                        <D_DTP02_DateTimePeriodFormatQualifier>D8</D_DTP02_DateTimePeriodFormatQualifier>
                        <D_DTP03_OnsetOfCurrentIllnessOrInjuryDate>20110405</D_DTP03_OnsetOfCurrentIllnessOrInjuryDate>
                      </S_DTP_DateOnsetOfCurrentIllnessSymptom_TS837Q1_2300>
                    </I_DTP_TS837Q1_2300>
                    <I_REF_TS837Q1_2300>
                      <S_REF_ClaimIdentificationNumberForClearingHousesAndOtherTransmissionIntermediaries_TS837Q1_2300>
                        <D_REF01_ReferenceIdentificationQualifier>D9</D_REF01_ReferenceIdentificationQualifier>
                        <D_REF02_ClearinghouseTraceNumber>21524 149026</D_REF02_ClearinghouseTraceNumber>
                      </S_REF_ClaimIdentificationNumberForClearingHousesAndOtherTransmissionIntermediaries_TS837Q1_2300>
                    </I_REF_TS837Q1_2300>
                    <S_HI_HealthCareDiagnosisCode_TS837Q1_2300>
                      <C_HI01_C022U862_TS837Q1_2300>
                        <D_HI01_C02201U863_DiagnosisTypeCode>BK</D_HI01_C02201U863_DiagnosisTypeCode>
                        <D_HI01_C02202U864_DiagnosisCode>V053</D_HI01_C02202U864_DiagnosisCode>
                      </C_HI01_C022U862_TS837Q1_2300>
                      <C_HI02_C022U870_TS837Q1_2300>
                        <D_HI02_C02201U871_DiagnosisTypeCode>BF</D_HI02_C02201U871_DiagnosisTypeCode>
                        <D_HI02_C02202U872_DiagnosisCode>V068</D_HI02_C02202U872_DiagnosisCode>
                      </C_HI02_C022U870_TS837Q1_2300>
                      <C_HI03_C022U878_TS837Q1_2300>
                        <D_HI03_C02201U879_DiagnosisTypeCode>BF</D_HI03_C02201U879_DiagnosisTypeCode>
                        <D_HI03_C02202U880_DiagnosisCode>V0382</D_HI03_C02202U880_DiagnosisCode>
                      </C_HI03_C022U878_TS837Q1_2300>
                    </S_HI_HealthCareDiagnosisCode_TS837Q1_2300>
                    <A_TS837Q1_2310>
                      <G_TS837Q1_2310D>
                        <S_NM1_ServiceFacilityLocation_TS837Q1_2310D>
                          <D_NM101_EntityIdentifierCode>77</D_NM101_EntityIdentifierCode>
                          <D_NM102_EntityTypeQualifier>2</D_NM102_EntityTypeQualifier>
                          <D_NM103_LaboratoryOrFacilityName>DOCTORS OFFICE</D_NM103_LaboratoryOrFacilityName>
                          <D_NM108_IdentificationCodeQualifier>XX</D_NM108_IdentificationCodeQualifier>
                          <D_NM109_LaboratoryOrFacilityPrimaryIdentifier>010101010</D_NM109_LaboratoryOrFacilityPrimaryIdentifier>
                        </S_NM1_ServiceFacilityLocation_TS837Q1_2310D>
                        <S_N3_ServiceFacilityLocationAddress_TS837Q1_2310D>
                          <D_N301_LaboratoryOrFacilityAddressLine>123 PEPPER ST</D_N301_LaboratoryOrFacilityAddressLine>
                        </S_N3_ServiceFacilityLocationAddress_TS837Q1_2310D>
                        <S_N4_ServiceFacilityLocationCityStateZIP_TS837Q1_2310D>
                          <D_N401_LaboratoryOrFacilityCityName>PITTSBURGH</D_N401_LaboratoryOrFacilityCityName>
                          <D_N402_LaboratoryOrFacilityStateOrProvinceCode>PA</D_N402_LaboratoryOrFacilityStateOrProvinceCode>
                          <D_N403_LaboratoryOrFacilityPostalZoneOrZIPCode>15123</D_N403_LaboratoryOrFacilityPostalZoneOrZIPCode>
                        </S_N4_ServiceFacilityLocationCityStateZIP_TS837Q1_2310D>
                      </G_TS837Q1_2310D>
                    </A_TS837Q1_2310>
                    <G_TS837Q1_2400>
                      <S_LX_ServiceLine_TS837Q1_2400>
                        <D_LX01_AssignedNumber>1</D_LX01_AssignedNumber>
                      </S_LX_ServiceLine_TS837Q1_2400>
                      <S_SV1_ProfessionalService_TS837Q1_2400>
                        <C_SV101_C003U947_TS837Q1_2400>
                          <D_SV101_C00301U948_ProductOrServiceIDQualifier>HC</D_SV101_C00301U948_ProductOrServiceIDQualifier>
                          <D_SV101_C00302U949_ProcedureCode>90744</D_SV101_C00302U949_ProcedureCode>
                        </C_SV101_C003U947_TS837Q1_2400>
                        <D_SV102_LineItemChargeAmount>15.76</D_SV102_LineItemChargeAmount>
                        <D_SV103_UnitOrBasisForMeasurementCode>UN</D_SV103_UnitOrBasisForMeasurementCode>
                        <D_SV104_ServiceUnitCount>1</D_SV104_ServiceUnitCount>
                        <D_SV105_PlaceOfServiceCode>11</D_SV105_PlaceOfServiceCode>
                        <C_SV107_C004U955_TS837Q1_2400>
                          <D_SV107_C00401U956_DiagnosisCodePointer>1</D_SV107_C00401U956_DiagnosisCodePointer>
                        </C_SV107_C004U955_TS837Q1_2400>
                      </S_SV1_ProfessionalService_TS837Q1_2400>
                      <I_DTP_TS837Q1_2400>
                        <S_DTP_DateServiceDate_TS837Q1_2400>
                          <D_DTP01_DateTimeQualifier>472</D_DTP01_DateTimeQualifier>
                          <D_DTP02_DateTimePeriodFormatQualifier>D8</D_DTP02_DateTimePeriodFormatQualifier>
                          <D_DTP03_ServiceDate>20110405</D_DTP03_ServiceDate>
                        </S_DTP_DateServiceDate_TS837Q1_2400>
                      </I_DTP_TS837Q1_2400>
                      <G_TS837Q1_2410>
                        <S_LIN_DrugIdentification_TS837Q1_2410>
                          <D_LIN02_ProductOrServiceIDQualifier>N4</D_LIN02_ProductOrServiceIDQualifier>
                          <D_LIN03_NationalDrugCode>00006498100</D_LIN03_NationalDrugCode>
                        </S_LIN_DrugIdentification_TS837Q1_2410>
                      </G_TS837Q1_2410>
                    </G_TS837Q1_2400>
                    <G_TS837Q1_2400>
                      <S_LX_ServiceLine_TS837Q1_2400>
                        <D_LX01_AssignedNumber>2</D_LX01_AssignedNumber>
                      </S_LX_ServiceLine_TS837Q1_2400>
                      <S_SV1_ProfessionalService_TS837Q1_2400>
                        <C_SV101_C003U947_TS837Q1_2400>
                          <D_SV101_C00301U948_ProductOrServiceIDQualifier>HC</D_SV101_C00301U948_ProductOrServiceIDQualifier>
                          <D_SV101_C00302U949_ProcedureCode>90698</D_SV101_C00302U949_ProcedureCode>
                        </C_SV101_C003U947_TS837Q1_2400>
                        <D_SV102_LineItemChargeAmount>15.76</D_SV102_LineItemChargeAmount>
                        <D_SV103_UnitOrBasisForMeasurementCode>UN</D_SV103_UnitOrBasisForMeasurementCode>
                        <D_SV104_ServiceUnitCount>1</D_SV104_ServiceUnitCount>
                        <D_SV105_PlaceOfServiceCode>11</D_SV105_PlaceOfServiceCode>
                        <C_SV107_C004U955_TS837Q1_2400>
                          <D_SV107_C00401U956_DiagnosisCodePointer>2</D_SV107_C00401U956_DiagnosisCodePointer>
                        </C_SV107_C004U955_TS837Q1_2400>
                      </S_SV1_ProfessionalService_TS837Q1_2400>
                      <I_DTP_TS837Q1_2400>
                        <S_DTP_DateServiceDate_TS837Q1_2400>
                          <D_DTP01_DateTimeQualifier>472</D_DTP01_DateTimeQualifier>
                          <D_DTP02_DateTimePeriodFormatQualifier>D8</D_DTP02_DateTimePeriodFormatQualifier>
                          <D_DTP03_ServiceDate>20110405</D_DTP03_ServiceDate>
                        </S_DTP_DateServiceDate_TS837Q1_2400>
                      </I_DTP_TS837Q1_2400>
                      <G_TS837Q1_2410>
                        <S_LIN_DrugIdentification_TS837Q1_2410>
                          <D_LIN02_ProductOrServiceIDQualifier>N4</D_LIN02_ProductOrServiceIDQualifier>
                          <D_LIN03_NationalDrugCode>49281051005</D_LIN03_NationalDrugCode>
                        </S_LIN_DrugIdentification_TS837Q1_2410>
                      </G_TS837Q1_2410>
                    </G_TS837Q1_2400>
                    <G_TS837Q1_2400>
                      <S_LX_ServiceLine_TS837Q1_2400>
                        <D_LX01_AssignedNumber>3</D_LX01_AssignedNumber>
                      </S_LX_ServiceLine_TS837Q1_2400>
                      <S_SV1_ProfessionalService_TS837Q1_2400>
                        <C_SV101_C003U947_TS837Q1_2400>
                          <D_SV101_C00301U948_ProductOrServiceIDQualifier>HC</D_SV101_C00301U948_ProductOrServiceIDQualifier>
                          <D_SV101_C00302U949_ProcedureCode>90670</D_SV101_C00302U949_ProcedureCode>
                        </C_SV101_C003U947_TS837Q1_2400>
                        <D_SV102_LineItemChargeAmount>15.76</D_SV102_LineItemChargeAmount>
                        <D_SV103_UnitOrBasisForMeasurementCode>UN</D_SV103_UnitOrBasisForMeasurementCode>
                        <D_SV104_ServiceUnitCount>1</D_SV104_ServiceUnitCount>
                        <D_SV105_PlaceOfServiceCode>11</D_SV105_PlaceOfServiceCode>
                        <C_SV107_C004U955_TS837Q1_2400>
                          <D_SV107_C00401U956_DiagnosisCodePointer>3</D_SV107_C00401U956_DiagnosisCodePointer>
                        </C_SV107_C004U955_TS837Q1_2400>
                      </S_SV1_ProfessionalService_TS837Q1_2400>
                      <I_DTP_TS837Q1_2400>
                        <S_DTP_DateServiceDate_TS837Q1_2400>
                          <D_DTP01_DateTimeQualifier>472</D_DTP01_DateTimeQualifier>
                          <D_DTP02_DateTimePeriodFormatQualifier>D8</D_DTP02_DateTimePeriodFormatQualifier>
                          <D_DTP03_ServiceDate>20110405</D_DTP03_ServiceDate>
                        </S_DTP_DateServiceDate_TS837Q1_2400>
                      </I_DTP_TS837Q1_2400>
                    </G_TS837Q1_2400>
                  </G_TS837Q1_2300>
                </G_TS837Q1_2000B>
              </G_TS837Q1_2000A>
              <S_SE>
                <D_SE01>41</D_SE01>
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